Eating Difficulties: Initial Assessment

This form covers the wide range of feeding/eating difficulties at varied ages. Please feel free to skip any question that is not relevant to your child.

Child Name

First Name

Last Name

Date of Birth

Parent Names

Phone

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cultural or spiritual considerations

Are there any cultural or spiritual practices that are important to you? These could be related to mealtimes or how we can work together?

Other health professionals

Please note any other professionals supporting your child. If you have relevant reports, please provided these prior to appointment

Medical history

Please describe relevant history including pregnancy/birth, early life, any illnesses or complications affecting eating

Diagnoses

Does your child have any current diagnoses?

Note any food or environmental allergies

Dietary restrictions

Note any foods you avoid other than for allergies. e.g., Cultural reasons, gluten-free, etc.

ORAL MOTOR SKILLS

Do you have any concerns with your child's oral-motor skills - such as chewing or swallowing?

Eating independence

Is your child showing eating independence that you would expect for their age? e.g., Please note any concerns you have with them feeding themselves, holding utensils, using age-appropriate cups or bottles, etc

Sensory sensitivity

Is your child sensitive to food properties? e.g, texture, temperature, utensils, touch on face

EATING ROUTINES

Please describe a typical day with approximate meals/feeding times (main meals/snacks), and any breast/formula feeding

FOODS OR DRINKS CONSUMED

Try to list the foods that your child consistently eats and how they eat them. e.g., Do they eat fruits, vegetables, proteins, carbohydrates? Do you have to change any aspect of the food (texture, cooking method, etc.?)

Describe behaviours that are challenging for you at meatlimes

How do you usually respond to these behaviours (e.g., distract, take food away, end meal, etc)

Does your child follow a certain routine with regards to eating (e.g., certain food must be present, order of things), or in any other situations?

Previous intervention/strategies

Please describe any other strategies you have followed/services you have received related to eating. What was helpful/not helpful?

Describe your child's strengths/abilities in other areas, activities that they like

GOALS

What are your goals, or your vision about your child's eating? How can I help?